An Interview With Ezekiel Emanuel

Before Ezekiel Emanuel joined his brother Rahm in the White House, he was director of the National Institute of Health's clinical bioethics programs and an oncologist specializing in breast cancer. Since he began advising President Obama's budget chief, Peter Orszag, on health care, however, he's become a surprisingly high-profile figure. A recent New York Post article dug through his academic papers and branded Emanuel one of Obama's "deadly doctors," accusing him of everything from wanting to refuse health care to the elderly to wanting to let the developmentally disabled perish. Reached in Italy this week, the man the New Republic called "the nicest" Emanuel brother struck back at his critics, explained what a bioethicist does and revealed his foodie side. An edited transcript of our conversation follows.

We've heard harsh accusations in the health-care debate lately, including Sarah Palin's contention that you want "death panels" and Rep. Virginia Foxx's charge that Democrats want "to put seniors in a position of being put to death by their government." So, do you want to euthanize my grandmother?

No. I've never met your grandmother. I'm sure she's a lovely lady.

Anybody else's grandmother?

No. I'm on record against legalizing euthanasia and assisted suicide for over a decade now. As you know from my Atlantic article.

I actually read that article in preparation for this interview. It made me rethink my position on euthanasia.

Wow! I've succeeded as an academic. That's fantastic!

So how did all this get started?

You're asking me? I'm just the victim here. All I know is the New York Post ran a article attacking me. I think lots of people decided it might be an easy way to kill health-care reform.

The New York Post quoted a 1996 article you wrote saying that some people believe health-care resources shouldn't go to those "who are irreversibly prevented from being or becoming participating citizens." What was your point?

I was examining two different, abstract philosophical positions to see what they might offer in the context of redoing the health-care system and trying to reduce resource consumption in health care. It's as abstractly philosophical as you can get on a practical question. I qualified it in 27 different ways, saying it wasn't my view.

Before you joined the White House, you were a bioethicist. What does a bioethicist do?

Worries about some of the hardest questions society has to face. One of the quotes in the New York Post came from an article we recently published in the Lancet where the question we were confronting may be the most difficult question the health-care system faces every day. We don't have enough solid organs for transplantation; not enough kidneys, livers, hearts, lungs. When you get a liver and you have three people who need it, who should get it? We tried to come up with an ethically defensible answer. Because we have to choose.

Our system is expensive in part because we've refused to choose, because we've refused to answer some of these questions, like how we deal with end-of-life care, or what minimum benefits should be guaranteed to every American. But isn't not answering those questions a sort of answer, too?

Yeah. You can't avoid these questions. Even if you don't provide an overt justification for them, you end up making decisions. Sometimes those aren't good decisions, or they're decisions you regret. We had a big controversy in the United States when there were a limited number of dialysis machines. In Seattle, they appointed what they called a "God committee" to choose who should get it, and that committee was eventually abandoned. Society ended up paying the whole bill for dialysis instead of having people make those decisions.

Many see the health-care system as aimed at preventing death, and whenever someone dies, that's a failure. So we don't build in options around death because that would be admitting the possibility of failure.

Having been an oncologist and having cared for scores, if not hundreds, of dying patients, when you don't have a treatment that can shrink the tumor and the patient will die, it's a very difficult conversation. It's emotionally draining. Then to talk to the family and figure out how to give the best quality of life in the final weeks or months -- those are hard decisions.

You've argued that one of the reasons we've had trouble achieving universal health care is that we don't have an agreed-upon ethical system for health care. As such, we don't argue from common premises and no one trusts each other.

Issues that we cannot seem to resolve in our society reflect a lack of shared values. The situation around Terri Schiavo was a deeply held conflict over what to do if someone isn't going to return to consciousness or competence. Who will decide? Even there, where we had settled legal rules, we still had disagreement. We're torn about these things.

Are the bills under consideration dealing with these problems?

Fifteen years ago, I thought that cost growth meant we would have to confront the rationing question. But the more I studied it, the less I think rationing of health care is the key question. The bigger question seems to be improving the quality and efficiency of the system. We have a lot of unnecessary care. The big issue here is how to redesign the health-care delivery system so we're doing the appropriate data-driven care that we know will improve someone's life and not doing unnecessary, and potentially harmful, care.

So it's not rationing if you don't need it?

I think we have so much unnecessary care that's not improving quality of life or length of life, that our first order of business is to get rid of that. That, we can all agree on. We need to change incentives, change how doctors behave and make decisions, so they're more focused on what the data shows.

A series of great meals at Cafe Atlantico. A quasi-Minibar they made for me was wonderful. I was there two weeks ago. They served about six or eight hors d'oeuvres, and then they had this series of small entrees that were spectacular. The crescendo was a duck confit that was brilliant.

I hear you're also trying to change how the federal government eats.

President Obama, about two months ago, had a number of CEOs of major American corporations explain how they improve the health and wellness of their workforce. I was charged with applying their ideas to the federal workforce. One of their ideas was to change the food and nutrition available to workers. Both at cafeterias and vending machines, giving them healthier options and subsidizing more nutritious foods, but also making available to them better foods they can bring home through farmers markets.

What is your brother Rahm's favorite food?

Good question. I don't know, actually.

I've heard it's the still-beating hearts of his enemies.

Oh, my brother is a lovely person. He doesn't do any of that.

One last question: If you're lying and you do create any death panels, can you put in a good word for me?

His answer really didn't address it. This really is a challenging question- not just on a political level-- but purely on a medical level.

"Waste" is determined at a population level. Treatment is determined at an individual level. A large study may suggest patients from a given patient population with certain baselines characteristics responds better to X than Y. Or no response at all. But when an individual patient and doctor are deermining treatment options, their particular situation is somewhat different, in some fashion, from the "average" patient in the study. At a population level, the correct treatment option is clear. But if YOU'RE the patient, the correct treatment option is a lot less clear.

When you translate this medical quandary into a political question, I'm not sure you can get away from "reducing waste" not being perceived as rationing. At least not in our current "me first" culture.

Ezra, Can you provide a link to Ezekiel Emanuel's work on improving the diet of State employees? As an employee of a State University Hospital, the amount of sugar, fat, and salt in the cafeteria is atrocious. I look forward to a change in policy.

Palin has no interest in health care reform. She is just a stooge for the Republican party. And each of her latest statements contains distortions and lies. There are related posts at http://iamsoannoyed.com/?page_id=588

'wisewon' commenting above targets two valid points: the question of vouchers is an option worth exploring and the question of 'Who decides' must somehow be addressed.

The 'settled rules' mentioned, are, sadly, from the start of the past century: at the time, women could not vote, the blood of 'races' could not co-mingle, and it was decided that the "principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes [of an unwilling patient]."

The question of rationing was nicely dodged, but also must be answered. The CS Monitor has been following the 'Do We Have Enough Doctors?' topic, and to date I've only seen carefully-crafted answers in the negative suggesting that [in paraphrase] 'People who in the past used physicians' time would be encouraged to utilize the services of nurse practitioners and lesser other-than-trained-physician staff members'.

In a nutshell, when you asked "Are the bills under consideration dealing with these problems?" you received a tactful answer 'No.'

The answers you received are probably the most sincere that I've read to date, and they are truly appreciated.

Perhaps we need to consider this whole health insurance reform issue a bit more: argument actually seems to be bringing valid ideas and concerns to public and legislative attention, with a small (and ultimately short-lived) penalty of some hot-headed angry words. Before creating yet another program to join the failures of Medicare and Medicaid, programs which even the President describes as "unsustainable", shouldn't we think -- actively think -- a bit more?

Even you, Ezra, have changed your position a bit in the course of the discussion: those of us not as intellectually agile as you might need some time to catch up. The only reason for haste seems to be some sort of misguided partisan warfare tactic... 'let's do this before people vote us out' versus 'let's do this so people will vote them out'.

Ah, but you can't assess "need." You evaluate an expensive procedure with a low success rate as "unnecessary" simply because not everyone benefits from it. For the people who *do* benefit from it, the same procedure is LIFE-SAVING.

By simply declaring it "unnecessary," you rationalize the rationing. IT IS RATIONING. You're intellectually dishonest, Ezra.

You take the one entity who arbitrates whether care is appropriate -- the one to whom doctors and insurers alike are all accountable -- and have it ration care on the basis that what is currently medically justifiable care is suddenly "unnecessary."

A person can get the procedure from his doctor. A person can get the procedure from his insurer. But you can't get the procedure from government: It's "unnecessary." Translation: RATIONING.

We are not talking about rationing health care, we are talking about rational health care.

When the Mayo Clinic can attain BETTER results at half or three-fourths the cost, when Kaiser Bay Area can reduce costs for cardiac care and at the same time the knock heart disease from its historic spot as the number one cause of death, and when almost every developed country can deliver health care for half to three-quarters what we do and get better results. Something is wrong.

Wisewon is right that every patient is different. But to some extent, that is an excuse, since as a doctor I also know that all patients are also the same. If they weren't medical care would be an impossible crap shoot.

Perhaps the best example we have is management of high blood pressure, one of the most common problems we have in the US. A few years ago, a very large study showed that the best steps to manage high blood pressure involved generic drugs that cost less than $100 a year. Last year, the scientists returned to the topic and found that many Americans were not receiving those treatments, but instead getting expensive proprietary drugs that had been proven less effective and more dangerous.

As long as we use meaningingless slogans rather than facts to govern health care, we are giving in to the forces that see health care as a cash machine rather than as a way to help people.

If you honestly believe that Mayo is doing a bad job at health care, then the comments higher on this thread make sense. If you do not, then they are just rhetoric designed to preserve a system that will bankrupt us at the same time that it denies many Americans the health care it needs.

Yawn. Now all you have to do is explain why all these insurance companies keep approving all these "irrational" procedures.

All I hear about is how they won't approve care if your hangnail is a pre-existing condition, yet all of a sudden now the problem is that insurance companies are approving too much "unnecessary" medicine. You can actually reconcile these inconsistencies? Knock yourself out.

Oh, and individual vouchers would be a lot more expensive than vouchers or subsidies on the health insurance exchange, because the insurance would be more expensive than with the HIE's negotiated rates. Either that or the voucher/subsidy would cover less of the insurance cost. Either way the HIE is a better deal for those seeking individual insurance.

How about reciprocity in organ donation? In other words, if you sign up to be a donor, and at some point in the future end up needing an organ yourself, then you get higher priority on the waiting list than someone who did not sign up to donate? It seems reasonable that those willing to accept an organ from someone else should also be willing to give one of their own if it came to that. This would encourage more people to sign up as donors who wouldn't sign up otherwise, greatly increasing the supply of organs and so saving many lives. There likely wouldn't be much if any net harm done to those who still choose not to donate, since those who do choose to donate will have added to the number of available organs at any given time, and so even if you're lower on the list than you would be otherwise, you'll still have about the same chance of getting an organ in time because the supply will be commensurately higher--though you still can improve your chances by agreeing to donate yourself. If there are donors who object to being given priority and wish do donate solely altruistically, they can be allowed to opt out of the priority privilege.

Doing a quick Google search it seems that there have been some proposals to do something like this, but I don't know what the public acceptance of such a reciprocal donation system would be. Any thoughts?

I'm jus going to talk about Atlantic article of March 1997 "Whose right to die." There's a link in the interview.

Please read it. As I did, I felt I was going on a ride as it drew me in and made me wonder if something I would have stridently approved of, might be wrong. Up, down, that can't be true, huh, you're kidding, what do you mean, really, well..

Forget the content if you wish, if you've got a mind that might be changed by argument it's worth reading just for the ride.

And at the end of the article, just like Klein, I've rethought my views on euthanasia and physician assisted suicide. They should be illegal.

To me, it explained the issues clearly and fairly and named and explained what research has shown. And it REEKS of compassion and concern for the elderly and the sick.

And this is a 'deadly doctor'? Baloney.

I'm 99 and 44/100th sure that if I track down the original source for the attacks against Emmanual, I'd find lies, grave distortions, quotations and summaries out of context.

One of the sorry outcomes of the artificially inflamed "debate" about "death panels" is that sensible people are being discouraged from expressing themselves. Specifically, the National Hospice and Palliative Care Organization e-mailed its hospice advocates to recommend against attending congressional town hall meetings, as a measure of how toxic that environment has become to honest discussion about advance care planning and end-of-life care. For the Palins and her ilk, no lie is too shameful to be repeated endlessly, thanks to the willingness of desperate Republicans to echo her and the unwillingness of most MSM to refuse to print obvious lies and distortions from serial dissemblers.

“Yawn. Now all you have to do is explain why all these insurance companies keep approving all these "irrational" procedures. “

Alas, facts are a stubborn thing. The fact is that some insurance companies do try to purge people when they make claims. The fact is that insurance companies (and Medicare) pay for a lot of ineffective, unnecessary care. The fact is that some American health care systems have found ways to eliminate unnecessary care and save a lot of money. Boring perhaps, but real.

We live in the world of Copernicus, not Plato. We have to deal with the world as it comes, not as we imagine it should be.

Rationing means distributing a scarce product fairly, like gasoline during World War II.

We don’t need that in health care, because we can tap into $800 billion per year in waste. What we are facing is the need for rational choices, like deciding that if you can’t afford both, you spend your paycheck for food for your kids, not for a visit to Six Flags.

"Others want low-income people to live as long (and be productive for as long) as high-income people."

Of course, if low-income people were as productive as high-income people are, then they wouldn't be low-income people, would they? Doesn't our system make some sort of statement about how it values people's productivity in their respective incomes?

Fortunately, there are so few actual facts around here as to render that statement irrelevant. What there is, however, is an enormous number of logic errors. And with "facts" like those, who needs lies?

Take this one, for example:
"The fact is that insurance companies (and Medicare) pay for a lot of ineffective, unnecessary care."

The real "fact" is that "ineffective" and "unnecessary" are subjective values. To an egalitarian idiot, for example, an expensive procedure that only benefits a small fraction of the patients who undergo it is "ineffective" or "unnecessary."

On the other hand, to a physician who is duty-bound to do everything possible for his patients, it would be irresponsible to not try such a procedure where it might help. And to the insurance company who might be sued if a potentially helpful procedure is forgone, it is cheaper to give the procedure to everybody it doesn't help than to be sued by everybody who can later claim that it might have helped but wasn't tried.

Now, there are two ways you can present these conflicting values. You can just give control of the decisions to the "ineffective and unnecessary" crowd and we can all pretend that nobody will is harmed by it, when the reality is that it will harm somebody but we'll just never know exactly whom.

Or you could choose to be honest, for a refreshing change, and admit that the few lives saved by very expensive and rarely effective procedures are simply not "worth" saving. That's what "unnecessary" really means.

Those are what real facts look like. No omissions. No spin. None of your lies. And you're right -- they're stubborn indeed.

The fact is that these procedures have more medical value than political value. And your choice of camps says a lot about your priorities as a doctor. I wouldn't want you treating my family.

I could just as easily shred some of your other premises, as well, but you're not worth the time, Doc.

“Fortunately, there are so few actual facts around here as to render that statement irrelevant.”

I see. This is an education problem.

There are, in fact, a ton of facts demonstrating that there is a large amount of unnecessary care. You might want to start by reading the Dartmouth Atlas data, collected over 30 years. You may wish to take a look at the Allhat study on anti-hypertensive drugs, as well as the subsequent follow-up showing that the results had largely been ignored. You may wish to look at the results of the multi-center study on low back pain. Investigation of the data on coronary artery disease management and the failure of interventional procedures to demonstrate any superiority to medical treatment in patients who are not having acute myocardial infarctions in progress would be worthwhile. You may be interested in the recent data on the poor utility of MRI of the knee in assessment of patients over fifty.

I could go on. However, it may be that you are not interested in the facts at all, since you make the statement that it is “fortunate” that you are unaware of most of the facts.

Finally, it is very important to note that we are not talking about expensive treatments to save a few lives. We are talking about the widespread use of medical management that is ineffective, or no more effective than much less expensive management, or is actually harmful. We are talking about instituting quality assurance that guarantees much higher levels of safety and effectiveness for all patients. We are talking about making medical care better for everyone, not about depriving people who need it of treatment.

I know this is confusing, particularly if you are mainly coming from the point of view that beliefs should not be tested against real facts. Give it a try. You might surprise yourself.

I have a better idea. Why don't you call up the insurance companies, and tell them that you can save them hundreds of millions of dollars by showing them all the procedures and meds they don't have to approve anymore?

The way I hear it, they're always looking for new ways of getting out of paying for people's care. It sounds like you've got a plan. You'd be doing them a favor.

In fact, it's amazing, when you stop to think about it, that the insurance companies don't hire their own doctors to tell them what procedures they should be approving and denying. It's hard to believe nobody's thought of that.

I do appreciate that you actually believe what you say. But you're ignoring some very powerful market forces (and the entire liberal war on "big insurance") when you suggest that the big, bad insurance companies don't already have sufficient incentives to trim procedural fat.

That's exactly what this is all about: giving insurers, both public and private, the traction they need to bring runaway spending on questionable care under control, before health care breaks the bank and the middle class and working class can no longer afford care.

What a delightful interview! For once I felt elated in this depressing debate, which is fundamentally about compassion and solidarity with “the Wreched of the Earth” – those 40 millions un- or underinsured. Of cause it is also a question about echonomics and resources and therefor an ethical debate.
Most importantly it is imperative to bring in knowledge rather than emotion. Bioethics is a little known academic exercise, but extremely important as far as it affects our day-to-day behaviour and , in fact, it is part of our commen values.
Thanks to Dr. Rahm and Mr. Klein.
However, many comments to this article show (once again) what happens when you cast pearls befor swine (with or without libstick).

This is a case of dishonesty by omission. You have left out the widely publicized quotes from Ezekiel Emanuel's talk at the Hastings Center in 1996, in which he said that health services (NOT TRANSPLANTS -- his word was services) should not be a given, should not be guaranteed to those who are irreversibly prevented from being "participating" (what the hell does that word mean anyway) citizens, an obvious case of which, he went on to say, would be denial of services (or non guarantee of services) to those suffering from dementia. Do you deny that he made that statement?

Dr. Zeke is lying. He is an untrustworthy interpreter of his own writings. In the Hastings report of 1996, he wrote it based on the assumption that "universal care" (aka Government run care) is/should be the goal of a "just" health system.

More problematic was his 2009 Lancet article which went beyond examining allocation strategies but promoted his own "Complete Lives System". It was NOT done for mere transplants (even the summary uses the phrase "such as" meaning that transplants and vaccines are just examples) but in the concluding pages includes the line that using Complete Lives for general healthcare is, at present, "premature." Dr. Zeke also contends discriminating against those 65 and older is "not invidious" and perfectly acceptable as a way of allocating healthcare services.

Thanks for the additional information. Cutesy is a good word. The point of the interview (and probably this was worked out in conjunction with patrons at the white house) was to hold up to ridicule doubts that have arisen about Ezekiel Emanuel. Thus the opening joke, "do you intend to kill my grandmother..." Access to the doctor and his phone number at his fabulous vacation place in Italy provided in return for this attempt to defang him.

"he wrote it based on the assumption that "universal care" (aka Government run care) is/should be the goal of a "just" health system."

So many errors, so little time.

As it happens, Ezekiel Emanuel has written a book about health care reform, "Healthcare Guaranteed." It's only 176 pages so you can read it in an evening.

In it, far from advocating "government run" health care, he advocates that everyone, including those who now would be covered by Medicare and Medicaid, be covered by private insurance. He suggests that the only role for the government is in providing money for people to be able to buy insurance in the form of vouchers for buying private insurance. He also endorses ending the employer paid system, an aggressive approach to malpractice reform involving removing malpractice from the court system, and using a value added tax (VAT) to provide necessary financing. Basically, he endorses almost every conservative trope on health care except for "let them die in the street."

"Universal care," of course, means that everyone has access to health care, not that the government provides health care. Universal care is the norm in all developed nations but ours, but there is wide range of ways it is provided, ranging from socialized medicine ala Britain to 100% private insurance, ala Switzerland. Emanuel happens to endorse 100% private insurance. Of course, his boss doesn't.

Like any academic he has a big paper trail. There are many ideas he has advocated. But there's no doubt that he's done a lot of thinking about what could be called "rationing" -- though he would never use that word. Allocation would be a more likely term. He therefore does not endorse every conservative trope. Yes, he has written against physician assisted suicide. That's not incompatible with the withholding of care to those who, in his words, "cannot be or become PARTICIPATING citizens". Just listen to the tone of that phrase -- participating citizens -- and consider that this is his criterion for worthiness to survive. Also consider the kind of mentality it would take to even try to name or put into words what makes a person's life acceptable, worth trying to save. At the bottom of that phrase is the idea that an individual's value is his value to the state, his value as a PARTICIPATING citizen. This is a godless thought, a thought that excludes the individual's value to his loved ones, and more deeply, to himself. This phrase is all you need to get a complete picture of the mind of the man who wrote it.